55 year old with giddiness and lethargy

55 year old male painter by occupation came to casualty with cheif complaints of
 
1.Giddiness since 2 days
2.lethargy since 1 day

Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom,he fell on his knees,no LOC,No involuntary movements of UL/LL

Taken to outside hospital found out to be having BP-250/120mm of hg, antihypertensives were given

From 1 day pt is lethargic, decreased responsiveness, brought to our hospital for further evaluation.

On presentation to casualty BP:180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg

PAST HISTORY:

K/C/O HTN since 2 years and on irregular medication,Not a K/C/O DM, Bronchial asthma,CAD

FAMILY HISTORY:

No family history of HTN, DM, bronchial asthma, epilepsy

GENERAL EXAMINATION:

Patient is conscious,coherent, cooperative,Oriented to time,place and person
No signs of pallor,icterus,cyanosis,lymphadenopathy&pedal edema
VITALS:

Temp:- 98.3 F
BP:- 180/120 mmhg
RR:- 20 cpm
PR:- 72 bpm
Systemic examination:-
CVS- S1, S2 heard,
RS:BAE present
CNS: 
          TONE UL LL
          Right Normal Normal
          Left Normal Normal

          POWER UL LL
           Right 4/5 4/5
           Left 4/5 4/5
           
        REFLEXES RIGHT LEFT
              B + + 
              T + +
              S + +
              K + +
              A + +
              P Flexion Flexion
Gait:gait
INVESTIGATIONS:

ECG:
USG abdomen:Impression-No sonological abnormality detected

MRI BRAIN( provisional)
Impression:
1.Acute infarct in putamen,globus pallidus on RT side which shows blooming on SWI-Likely Hemorrhagic transformation
2.Old infarct in left side of pons
3.B/L periventricular hyperintensities on T2/FLAIR-S/O small vessel ischaemic changes

DIAGNOSIS:

CVA with Acute infarct in putamen,globus pallidus on RT side 
With Hemorrhagic transformation Hypertensive urgency with
 K/C/O HTN since 2 years

TREATMENT:

1.BP MONITORING HOURLY
2.STRICT I/O CHARTING
SOAP
3.TAB.TELMA-H PO OD

SOAP notes day 1:
S- C/O Giddiness reduced compared to yesterday
 C/O Generalized weakness
O-
O/E:Pt-C/C/C
Temp:Afebrile
PR:84bpm
BP:160/100 mm of hg
RR:18cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
CNS: 
E4V5M6

          TONE UL LL
          Right Normal Normal
          Left Normal Normal

          POWER UL LL
           Right 4/5 4/5
           Left 4/5 4/5
           
        REFLEXES RIGHT. LEFT
              B + + 
              T + +
              S + +
              K + +
              A + +
              P Flexion Flexion
              
A:CVA with Acute infarct in putamen,globus pallidus on RT side 
With Hemorrhagic transformation Hypertensive urgency with
 K/C/O HTN since 2 years

P:
1.BP MONITORING HOURLY
2.STRICT I/O CHARTING
3.TAB.TELMA-H PO OD

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